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Open AccessVol 11 No 4 Research A survey of Canadian intensivists' resuscitation practices in early septic shock Lauralyn A McIntyre1, Paul C Hébert1, Dean Fergusson2, Deborah J Cook3, A

Open Access

Vol 11 No 4

Research

A survey of Canadian intensivists' resuscitation practices in early septic shock

Lauralyn A McIntyre1, Paul C Hébert1, Dean Fergusson2, Deborah J Cook3, Ashique Aziz4 for the Canadian Critical Care Trials Group

1 University of Ottawa Centre for Transfusion and Critical Care Research, Clinical Epidemiology Unit of the Ottawa Hospital, Ottawa Health Research Institute, 501 Smyth Rd Ottawa, Ontario, Canada K1H 8L6

2 Ottawa Health Research Institute, Clinical Epidemiology Program of the Ottawa Hospital, 501 Smyth Rd, Ottawa, Ontario, Canada, K1H 8L6

3 Clarity Research Group, Department of Medicine and Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Centre, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5

4 Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada

Corresponding author: Lauralyn A McIntyre, lmcintyre@ottawahospital.on.ca

Received: 13 Apr 2007 Revisions requested: 17 May 2007 Revisions received: 27 Jun 2007 Accepted: 10 Jul 2007 Published: 10 Jul 2007

Critical Care 2007, 11:R74 (doi:10.1186/cc5962)

This article is online at: http://ccforum.com/content/11/4/R74

© 2007 McIntyre et al.; licensee BioMed Central Ltd

This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Introduction Recent evidence suggests that early, aggressive

resuscitation in patients with septic shock reduces mortality

The objective of this survey was to characterize reported

resuscitation practices of Canadian physicians caring for adult

critically ill patients with early septic shock

Methods A scenario-based self-administered national survey

was sent out to Canadian critical care physicians One

hypothetical scenario was developed to obtain information on

several aspects of resuscitation in early septic shock, including

monitoring and resuscitation end-points, fluid administration, red

blood cell transfusion triggers, and use of inotropes The

sampling frame was physician members of Canadian national

and provincial critical care societies

Results The survey response rate was 232 out of 355 (65.3%).

Medicine was the most common primary specialty (60.0%),

most respondents had practiced for 6 to 10 years (30.0%), and

82.0% were male The following monitoring devices/parameters

were reported as used/measured 'often' or 'always' by at least

89% of respondents: oxygen saturation (100%), Foley catheters

(100%), arterial blood pressure lines (96.6%), telemetry

(94.3%), and central venous pressure (89.2%) Continuous monitoring of central venous oxygen saturation was employed 'often' or 'always' by 9.8% of respondents The two most commonly cited resuscitation end-points were urine output (96.5%) and blood pressure (91.8%) Over half of respondents used normal saline (84.5%), Ringers lactate (52.2%), and pentastarch (51.3%) 'often' or 'always' for early fluid resuscitation In contrast, 5% and 25% albumin solutions were cited as used 'often' or 'always' by 3.9% and 1.3% of respondents, respectively Compared with internists, surgeons and anesthesiologists (odds ratio (95% confidence interval): 9.8 (2.9 to 32.7) and 3.8 (1.7 to 8.7), respectively) reported greater use of Ringers lactate In the setting of a low central venous oxygen saturation, 52.5% of respondents reported use of inotropic support 'often' or 'always' Only 7.6% of physicians stated they would use a red blood cell transfusion trigger of 100 g/l to optimize oxygen delivery further

Conclusion Our survey results suggest that there is substantial

practice variation in the resuscitation of adult patients with early septic shock More randomized trials are needed to determine the optimal approach

Introduction

Severe sepsis accounts for approximately 3% of admissions

to hospital and 10% of admissions to the intensive care unit

(ICU), and it is the 10th leading cause of death in the ICU

[1,2] Despite decades of intense therapeutic investigation,

the mortality from severe sepsis and septic shock remains between 30% and 60% [3,4]

Aggressive resuscitation is the cornerstone of early treatment for patients with severe sepsis and septic shock [5] In a

CI = confidence interval; ICU = intensive care unit; OR = odds ratio; RBC = red blood cell; ScvO2 = central venous oxygen saturation; TRICC = Transfusion in Critically Ill.

landmark randomized controlled trial of goal-directed therapy

in early septic shock, hospital mortality in the goal-directed

group was reduced by 17% [6] Both standard therapy and

goal-directed therapy groups received algorithm driven care,

with resuscitation end-points including mean arterial pressure,

central venous pressure, and urine output as goals However,

an additional resuscitation end-point for the goal-directed

resuscitation group was to achieve central venous oxygen

resulted in greater use of dobutamine, red blood cell (RBC)

transfusions, and significant amounts of crystalloid and colloid

fluid during the first 6 hours of care [6] Given the many

differ-ent intervdiffer-entions in algorithm driven care, it is unclear which

aspect of the goal-directed intervention influenced survival

most

To elucidate self-reported resuscitation interventions and

describe which aspects of goal-directed therapy are used by

Canadian ICU physicians, we conducted a national survey of

early adult septic shock resuscitation management

Materials and methods

Study participants

A self-administered survey was sent to Canadian critical care

physicians identified using national and provincial critical care

society mailing lists The lists were verified and supplemented

by contacting all major critical care program directors in each

province We merged lists and de-duplicated names, and

identified 489 potentially eligible physicians We then

excluded fellows, retired members, physicians practicing

out-side Canada, pediatric intensivists, and physicians with no

for-warding address In total, 355 critical care practitioners were

ultimately considered eligible and were mailed the survey

between January 2004 and May 2004

Survey development

The scenario and corresponding questions were developed

through an iterative process among the investigative team, and

in consultation with members of the Canadian Critical Care

Trials Group, representing 140 critical care clinicians from

across the country One scenario was chosen to represent a

typical patient with septic shock, which also enabled survey

completion within 10 min to minimize respondent burden

The scenario described a 55-year-old woman in the

emer-gency room with vital signs compatible with septic shock after

a 1 l bolus of normal saline We described an older patient to

reflect the commonest age profile of this population, and

because older age is associated with increased mortality from

septic shock [2] (Additional file 1) Three questions were

asked to elucidate usual monitoring parameters, volume

resus-citation end-points, and resusresus-citation fluid preferences We

then altered the scenario to reflect the same patient but with

optimized intravascular volume and blood pressure, reduced

metabolic demand, and inadequate oxygen delivery

(norepine-phrine) in the scenario because it is often considered a first-line vasopressor agent for use in septic shock [7] The patient was mechanically ventilated with sedation and analgesia to represent a situation in which metabolic demand had been minimized We then asked whether physicians would inter-vene with RBCs and inotropic agents in response to a low

with five questions eliciting information on resuscitation end-points and interventions (Additional file 1) A 5-point Likert scale (never, rarely, sometimes, often, always) was used to elicit answers about preferred monitoring parameters, volume resuscitation end-points, resuscitation fluid, and inotropes For the RBC transfusion trigger question, we divided the hemo-globin level into seven distinct thresholds (60, 70, 80, 90, 100,

110, and 120 g/l), because previous surveys demonstrated that 95% of physicians chose transfusion thresholds for the critically ill that were consistent with the ones in our survey [8,9]

We also recorded information on physician and institution characteristics, including age, sex, primary specialty (medi-cine, surgery, anesthesia, or other), years in practice (0 to 5, 6

to 10, 11 to 15, or >15), number of weeks worked in the ICU (0 to 10, 11 to 20, or >20), and academic affiliation (university

or community hospital)

Survey preparation

The scenario was assessed for content, clarity, and realism by

17 members of the Canadian Critical Care Trials Group who piloted the survey The survey was translated into French for physicians who lived in Quebec, Canada The Research Eth-ics Committee of the Ottawa Hospital approved this study

Survey administration

We mailed the survey with a pre-stamped envelope Physi-cians who had not yet returned their forms received a reminder postcard 4 to 6 weeks after the first mailing After another 4 to

6 weeks, nonrespondents were sent a second survey

Statistical analysis

We described physician and institution characteristics (age, sex, primary specialty, years in practice, weeks worked in ICU, and academic affiliation) as well as the different resuscitation interventions (normal saline, Ringers lactate, pentastarch, RBC transfusion triggers, inotropes) using proportions All resuscitation intervention responses were dichotomized into often/always versus sometimes/rarely/never Reported moni-toring parameters and volume resuscitation end-points were graphically represented by using a compressed 5-point Likert scale (often/always, sometimes, and rarely/never)

To examine practice variation regarding resuscitation interven-tion variables, we conducted multivariable logistic regression analyses The dependent variables included all resuscitation

interventions (normal saline, Ringers lactate, pentastarch,

RBCs, and inotropes, dichotomized into always/often versus

sometimes/rarely/never) Independent variables were forced

into the models and included all ICU physician characteristics

(age (increasing increments of 10 years), sex, primary

spe-cialty (medicine, surgery, anesthesia, other), years in practice

(0 to 5, 6 to 10, 11 to 15, >15 years), and weeks worked in

the ICU (0 to 10, 11 to 20, >20)) We expressed associations

identified in the multivariable analyses as odds ratios (ORs)

and 95% confidence intervals (CIs) An OR of less than 1 was

associated with less frequent use of the resuscitation

interven-tion, and an OR of greater than 1 was associated with more

frequent use

Results

Survey respondents

We identified a total of 489 potential respondents From this

list, 134 were deemed ineligible for the following reasons: they

did not primarily practice critical care (n = 50), they did not

treat adults in their practice (n = 23); they were retired (n = 4);

or their address was unknown (n = 57) A total of 232 of 355

eligible respondents replied (response rate 65.3%) The

phy-sicians who responded mostly specialized in medicine

(60.0%), had been practicing for 6 to 10 years (30.0%), and were primarily male (82.0%; Table 1)

Resuscitation monitors and end-points

The following monitoring devices/parameters were reportedly used 'often' or 'always' by at least 89% of respondents to mon-itor early septic shock: oxygen saturation (100%), foley cathe-ters (100%), arterial blood pressure lines (96.6%), telemetry (electrocardiographic monitoring; 94.3%), and central venous pressure (89.2%; Figure 1) The pulmonary artery catheter and

by 24.7% and 9.8% of respondents, respectively ICU physi-cians reported use of several physiologic measures (resuscita-tion end-points) 'often' or 'always' to evaluate whether a patient was adequately volume resuscitated in the early phases of septic shock (Figure 2) Urine output and blood pressure were reported as used 'often' or 'always' most fre-quently (96.5% and 91.8%, respectively), followed by heart rate (79.5%), peripheral perfusion (78.9%), central venous pressure (78.7%), and a sustained rise in central venous pres-sure in association with a fluid challenge (69.3%) Of

end-point 'often' or 'always'

Resuscitation interventions

Normal saline, Ringers lactate, and pentastarch were reported

as used 'often' or 'always' by 84.5%, 52.2%, and 51.3% of respondents, respectively, as resuscitation fluids of choice for early septic shock (Table 2) Use of 5% and 25% albumin was less common (3.9% and 1.3% or respondents, respectively) The combination of normal saline, Ringers lactate, and pentas-tarch were reported as used 'often' or 'always' by 21.9% of physicians; 5.2% stated that they used normal saline alone; 0.5% stated that they used Ringers lactate alone; and 5.7% stated that they used crystalloid fluid alone (normal saline and Ringers lactate) No physicians stated that they would use pentastarch alone 'often' or 'always' as their resuscitation fluid Only 7.6% of ICU physicians reported that they would

50% in a patient who had reduced metabolic demand and optimized intravascular volume and blood pressure However, 76.8% of physicians stated that they would use a hemoglobin transfusion trigger of 80 g/l or less Of physicians, 52.5% stated that they would use inotropes 'often' or 'always' if the

and blood pressure optimization, minimization of metabolic demand, and administration of RBCs to improve oxygen deliv-ery (Table 2)

Influence of physician characteristics on responses

Using multivariable analyses, we also examined whether differ-ent physician characteristics (age, sex, primary specialty, years

in practice, weeks worked in ICU) were associated with differ-ential use of fluids, RBCs, and inotropes Anesthesiologists

Table 1

Physician characteristics

Physician characteristics Percentage

Primary specialty

Number of years in practice

Number weeks worked in ICU

Academic affiliation

There were 232 respondents in total ICU, intensive care unit; SD,

standard deviation.

(OR 3.8, 95% CI 1.7 to 8.7) and surgeons (OR 9.8, 95% CI

2.9 to 32.7), compared with internists, reported greater use of

Ringers lactate (Figure 3) Physicians who spent less time

working in the ICU reported lower use of Ringers lactate as

compared with those who spent 20 weeks per year or more

working in the ICU (0 to 10 weeks: OR 0.2, 95% CI 0.1 to 0.7;

11 to 20 weeks: OR 0.4, 95% CI 0.1 to 0.9; Figure 3)

Anesthesiologists were more likely than internists to report

using a RBC transfusion trigger of 80 g/l or less (OR 3.9, 95%

CI 1.2 to 12.9; Figure 4) No associations were detected

between physician characteristics and use of pentastarch or

inotropic agents (Figures 3 and 4, respectively)

Discussion

The results of our survey suggest that Canadian ICU

physi-cians commonly use crystalloid fluids such as normal saline

and ringers lactate, and the colloidal fluid pentastarch for early

septic shock resuscitation; use of albumin is reportedly much

less frequent Blood pressure and urine output were cited as the two most common volume resuscitation end-points Among different specialties, physicians also appear to have divergent fluid resuscitation preferences; indeed, anesthesiol-ogists and surgeons reported greater use of Ringers lactate than did internists Compared with internists, anesthesiolo-gists also more frequently reported using a low hemoglobin transfusion trigger of 80 g/l or less

Interestingly, only 10% of Canadian ICU physicians stated that

this monitoring parameter was available for early septic shock However, 53% said that they would use intropic agents, and all physicians stated they would transfuse patients in response

they may use it intermittently or in some patients to help guide therapy We conclude that the protocol presented by Rivers

Figure 1

Monitoring parameters used by ICU physicians

Monitoring parameters used by ICU physicians BP, intra-arterial blood pressure; CVP, central venous pressure; CVP oxy, continuous monitoring of central venous oxygen saturation; Foley, Foley catheter; ICU, intensive care unit; O2 sat, oxygen saturation; PAC, pulmonary artery catheter; Telem, telemetry.

Figure 2

ICU physicians stated volume resuscitation end-points

ICU physicians stated volume resuscitation end-points BP, blood pressure; CO, cardiac output; CVP, central venous pressure; CVP rise, sustained rise in central venous pressure; HR, heart rate; ICU, intensive care unit; MvO2, mixed venous oxygen saturation; Per Perf, peripheral perfusion; ScvO2, central venous oxygen saturation; UO, urine output.

and coworkers [6] for early septic shock resuscitation has

been variably adopted by Canadian ICU physicians, perhaps

for several reasons

Although it was a well conducted landmark trial in

goal-directed resuscitation, supported by the Surviving Sepsis

Campaign Guidelines for management of severe sepsis and

septic shock [10], it was a single-center study and has not yet

been replicated Although some centers have evaluated and

adopted this early goal-directed resuscitation protocol as part

of their clinical practice [11-15], many questions remain The

benefit seen in the early goal-directed group may have been

due to expedient resuscitation rather than continuous

negative results of the goal-directed resuscitation trial con-ducted by Gattinoni and coworkers [18], which incorporated

reported by Rivers and coworkers could be the time to initiate goal-directed therapy Rivers and colleagues randomized patients into the study within 1 hour of arrival in the emergency room, whereas Gattinoni and coworkers enrolled patients within 48 hours of admission to the ICU [17,18] Furthermore,

it is unclear whether intermittent as compared with continuous

septic shock Another reason for reported low adoption of

resources In a survey of 30 academic emergency room physi-cians from the USA, only 7% reported use of early

goal-Table 2

Resuscitation interventions

Fluid intervention

Fluid intervention combinations

Normal saline + ringers lactate + pentastarch 21.9

Red blood cell transfusion trigger (g/l)

Inotropes

There were 232 respondents in total The percentages reflect an 'often' or 'always' response to questions regarding the resuscitation

interventions.

Figure 3

Association between physician characteristics and resuscitation fluids

Association between physician characteristics and resuscitation fluids The figure shows the association between resuscitation fluid preferences and intensive care unit (ICU) physician characteristics using multivariable logistic regression analyses An odds ratio below 1 reflects less frequent use (sometimes/rarely/never) of the resuscitation intervention An odds ratio greater than 1 reflects increased frequent use (always/often) of the resuscitation intervention.

Figure 4

Association between physician characteristics and resuscitation interventions

Association between physician characteristics and resuscitation interventions The figure shows the association between resuscitation intervention preferences and intensive care unit (ICU) physician characteristics using multivariable logistic regression analyses An odds ratio below 1 reflects less frequent use (sometimes/rarely/never) of the resuscitation intervention An odds ratio above 1 reflects increased frequent use (always/often) of the resuscitation intervention RBC, red blood cell.

directed therapy in the emergency room Major reported

barri-ers for implementation of early goal-directed therapy included

the need for specialty monitoring equipment (75%), amount of

resources needed (43%), the need for central venous catheter

cannulation (36%), and too much emergency physician time

required (29%) [19]

was below 70% was a controversial aspect of the Rivers

resuscitation algorithms Results of our survey suggested that

only 7% of physicians would transfuse at a hemoglobin of 100

g/l, and 75% stated they would transfuse at a target

hemo-globin that was as low as 80 g/l or less An important reason

for accepting a lower RBC transfusion trigger in the critically

ill patient population probably relates to evidence from the

Canadian led Transfusion in Critically Ill (TRICC) trial [20],

which demonstrated a lower transfusion trigger (hemoglobin

70 g/l) was just as effective as a more conservative transfusion

trigger (hemoglobin 90 g/l) However, results from the TRICC

trial may not apply to patients with early septic shock, because

patients with sepsis represented only 5% of the TRICC patient

population [21] Furthermore, the study by Rivers and

cowork-ers did not specifically address the question of an optimal

RBC transfusion trigger in this setting, and hence it is difficult

to know whether this liberal transfusion trigger was

responsi-ble for the mortality benefit seen in the goal-directed group

Half of our survey respondents indicated that they would start

uni-form response may be related to concerns that use of these

agents could potentially worsen myocardial oxygen

consump-tion and cardiac arrhythmias in the setting of a heart that is

already in high demand [22,23] Furthermore, because the

study by Rivers and coworkers was not specifically designed

to test whether an inotropic agent improved outcome, it is

dif-ficult to know whether the contribution of inotropes, among

many other components of the protocol in the intervention arm,

was primarily responsible for the mortality benefit seen in the

goal-directed group

We found heterogeneous responses with regard to choice of

resuscitation fluids in early septic shock Although normal

saline, Ringers lactate, and the colloid pentastarch were used

at least 50% of the time, the use of either 5% or 25% albumin

was infrequent Reasons for minimal use of albumin may be

related to the findings of a previous meta-analysis that

sug-gested that albumin was not beneficial and was potentially

harmful [24] However, results from the Saline versus 4%

Albumin Fluid Evaluation (SAFE) study has put some of this

controversy to rest [25] That study was a randomized

control-led trial of 6,997 heterogeneous critically ill patients in need of

volume resuscitation, which compared 4% albumin with

nor-mal saline It found no difference in 28-day mortality between

the two groups, but there was a trend toward lower mortality

in a subgroup of patients with severe sepsis who received

albumin (relative risk ratio of 0.87, 95% CI 0.74 to1.02) The results of this subgroup analysis have served to fuel the debate with regard to superiority of colloidal as compared with crystalloid fluid resuscitation in the setting of severe sepsis and septic shock, and call for a large prospective, randomized trial to confirm or refute this hypothesis

Our survey examined stated adult ICU physician resuscitation practices within the context of early septic shock There are four previously published critical care surveys Two reflect European [26,27] and two reflect Canadian [28] and USA resuscitation practices [19] The Canadian and European sur-veys focused specifically on choice of resuscitation fluids and rationale for these choices in heterogeneous critically ill patient populations The US survey reported on the use and barriers to implementation of early goal-directed therapy [19],

as compared with our survey, which elicited stated practices for both resuscitation monitoring techniques and numerous therapeutic interventions

There are several potential limitations to the methods used in this study, including response bias and response rate For example, the use of a hypothetical scenario may have resulted

in critical care physicians stating that they use resuscitation parameters similar to those described by Rivers and cowork-ers more often than in actual practice It is also possible that one of our questions on the RBC transfusion trigger might have prompted reports of a more restrictive transfusion trigger because we, the survey investigators, had conducted the only major randomized trial in this field It is difficult to predict how the 35% of individuals who did not respond may have answered the questions and influenced the results and inter-pretation of the findings However, it is difficult to speculate whether the nonresponding physicians would be entirely homogeneous and sufficiently different in their answers, and thus impact on our overall results The universal caveat for all surveys holds for this one as well; what physicians say they do may not reflect what they actually do

This survey examined the very topical issue of resuscitation in septic shock, a condition associated with high mortality We surveyed physicians with different base specialties in univer-sity affiliated and community hospitals Although surveys of stated practice may not reflect actual practice [8,20], it is important to conduct surveys early in research programs designed to address vexing problems such as resuscitation strategies, because they provide essential background infor-mation for the design of these trials

Conclusion

Our survey identified extremely diverse practices, which sug-gest a bright future for resuscitation research Well designed randomized controlled trials addressing specific resuscitation questions with clinically important end-points have the

great-est potential to improve the care and outcomes in this

vulner-able population

Competing interests

In 2003, Edwards Life Sciences provided Dr LA McIntyre with

an $8000 unrestricted educational grant to help perform a

pilot randomized controlled trial that examined the role of fluids

in the setting of early septic shock However, Edwards Life

Sciences has not provided any funding for this present study

Authors' contributions

LM was responsible for the conception and design of the

study, analysis of data, manuscript drafting, and all manuscript

revisions DC, DF, and PH aided with study design, data

anal-ysis and drafting, as well as manuscript revisions AA aided

with data analysis and manuscript revision

Additional files

Acknowledgements

Authors would like to thank the Canadian Critical Care Trials Group and Steven Doucette for their assistance in the design and analysis of this survey Thanks also to Jodi Peters for her excellent administrative sup-port in the final preparation of this article.

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Key messages

▪ Our survey response rate was 232 out of 355 (65.3%)

▪ The following parameters/monitoring devices were

reported as used 'often' or 'always' by at least 89% of

respondents: oxygen saturation (100%), Foley

cathe-ters (100%), arterial blood pressure lines (96.6%),

telemetry (94.3%), and central venous pressure

9.8% of the time

▪ The two most commonly cited resuscitation end-points

were urine output (96.5%) and blood pressure (91.8%)

▪ Over half of respondents used normal saline (84.5%),

Ringers lactate (52.2%), and pentastarch (51.3%)

'often' or 'always' for early fluid resuscitation; in

con-trast, 5% and 25% albumin solutions were cited as

used 'often' or 'always' by 3.9% and 1.3% of

respond-ents, respectively

stated that they used inotropic support 'often' or

'always'; only 7.6% of physicians stated that they would

use a RBC transfusion trigger of 100 g/l to optimize

oxygen delivery further

The following Additional files are available online:

Additional file 1

A Word document containing the septic shock

resuscitation survey questions

See http://www.biomedcentral.com/content/

supplementary/cc5962-S1.doc

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